When expert dermatologists were asked about how they were using combination therapies in their practice, they offered varying and sometimes differing approaches to areas that they address most commonly.

Full face: Dr. Jacob

“Combination techniques are often based on dermatologists’ experiences in using the noninvasive approaches, along with the science behind the individual techniques,” said Chicago dermatologist Carolyn Jacob, MD.

Dr. Jacob treats a young patient population. Many are experiencing only the first signs of aging in their faces — predominantly around the eyes — and Dr. Jacob finds that a combination approach helps them retain an overall youthful look.

“A lot of my patients complain about loss of volume under the eyes,” said Dr. Jacob, an associate instructor in dermatology at Northwestern Memorial Feinberg School of Medicine in Chicago. She uses a combination of fillers, a neuromodulator, and, sometimes, lasers to address the issue. She also uses a hyaluronic acid under the eyes to build volume.

“However, in a lot of these cases, patients also have loss of volume in the mid-cheek, temples, lower-lateral cheeks and, sometimes, marionette area,” Dr. Jacob said. “For those areas, volume is what I think is needed. I use a poly-L-lactic acid filler throughout the cheeks and temples and marionette area because it gives a natural production of your own collagen, and softens the facial appearance without looking done.’” She combines the fillers initially, following up with a series of poly-L-lactic acid treatments and hyaluronic acid touchups every six to 12 months.

In some cases, Dr. Jacob also adds treatment with a neuromodulator, such as abobotulinumtoxinA, to address the glabellar area.

“I do the injectable wrinkle relaxer, first; a hyaluronic acid, second; and a poly-L-lactic acid, third. That’s just because the poly-L-lactic acid can distort the area under the eyes,” she said. “I use abobotulinumtoxinA in the majority of my patients because I find that it sets in faster, and in some patients lasts longer than botulinum toxin. Studies have shown that it lasts longer in the forehead, and works better in the crow’s feet [both off-label treatment areas].”

For patients also bothered by the red blood vessels on their nose and cheeks, Dr. Jacob will add treatment with a potassium-titanyl-phosphate (KTP) laser, prior to the neuromodulator and hyaluronic acid.

For some cases, Dr. Jacob also recommends resurfacing with a fractionated CO2 laser, although this is a treatment she reserves for second visits.

“I don’t do the resurfacing on the same day as the fillers or neuromodulators. Sometimes you get a little bit of swelling, which would distort how much filler I need to use. And I don’t want to put in the line filler and then laser over it with the fractionated laser because it could destroy a fraction of the product, depending on how superficially the product was placed,” she said.[pagebreak]

Eyes and Hands: Dr. Katz

Bruce Katz, MD, clinical professor at Mount Sinai School of Medicine in New York City, agrees with Dr. Jacob’s assessment that combination techniques are based on personal experience, but that each technique has had scientific studies behind them individually. His own experience with combination therapies for eyes had led him to a different method he finds effective for rejuvenating the area around the eyes.

“We do fractional C02 resurfacing of the eyelids. The nice thing about that is we can usually do just three or four treatments, so there’s minimal downtime,” Dr. Katz said. “Then, we do onabotulinumtoxinA or botulinum toxin for the crow’s feet to prevent them from coming back after the laser. But that doesn’t take care of the deep tear troughs. For those, we use non-animal stabilized hyaluronic acid or hyaluronic acid gel.”

Dr. Katz explained he uses those particular fillers because other non-hyaluronic acid fillers are too heavy to inject under the thin, delicate eyelid skin and may be visible.

This combination approach results in a major cosmetic improvement in the eyelids, he said.

The hands are another area of the body where Dr. Katz has observed benefits from combination therapies, and he has found that using a combination of laser and filler treatments is an ideal combination for rejuvenating aging hands, which are often one of the earliest spots to show signs of aging.

“A lot of men and women have dark spots or sun spots on the backs of the hands and their hands start to become bony looking. The tendons and the veins become a lot more prominent,” he said. “What we do is use the laser to remove the sun spots. Then, we use a volumizing filler to fill in the hands to make the tendons and veins less noticeable.”

He offers this final pearl for a successful outcome: Make sure to massage the filler into the hand so that it doesn’t look lumpy.

The Midface: Dr. Glogau

Fillers have long been a part of the aesthetic dermatologist’s armamentarium and a variety of products have entered the market. Now dermatologists are discovering innovative ways to use them in various combinations for optimal results.

Dermatologist Richard Glogau, MD, uses a single filler but in a combination of different concentrations to address midface volume loss. According to Dr. Glogau, clinical professor of dermatology at University of California, San Francisco, the trend is away from using fillers simply as wrinkle treatments and toward using hyaluronic fillers for deep tissue volume reconstruction.

“Building up the area that’s lost to aging in front of the malar cheekbones and in the midface has a lot more importance than trying to attack lines in the dermis or skin folds,” he said. “The paradox is that we’re using the hyaluronic fillers in lower concentrations. We’re actually diluting them to flood just underneath the skin and stimulate collagen production.”

Dr. Glogau also offered some recommendations for his approach to other areas, like the upper lip and around the eyes, suggesting a diluted hyaluronic filler to enhance volume. He added that he uses a concentration hyaluronic filler to add volume in deeper areas of the midface.

Watch for pitfalls

Combination therapies are made of individual therapies, each with benefits and risks. Dermatologists are advised to use caution when using common combination therapies.

Richard Glogau, MD, combines botulinum toxin with fillers to address aging around the mouth, but warns that using this approach can be tricky. “Producing symmetry in muscle action with the botulinum toxin around the mouth is difficult,” he said. To address the downturn that occurs at the corners of the mouth, dermatologists commonly use botulinum toxin in the depressor anguli oris, while using a filler in the marionette lines. The pitfall, according to Dr. Glogau, is producing exactly the same amount of muscle depression in one side as the other.

“This symmetry is important because the mouth moves very symmetrically particularly with speech. It’s a less forgiving area than botulinum toxin used on the brow area,” Dr. Glogau said.

Dermatologists avoid the asymmetry with proper dosing and placement. “When in doubt, go a little further laterally. The problem occurs usually when you put your injection points along the jawline, at the base of the depressor anguli oris muscle. You want to keep your injection point more lateral than medial. If you shoot medially the drug will infuse up into the depressor labia muscle, which controls the lower lip,” he said.

Combination therapies are made of individual therapies, each with benefits and risks. Dermatologists are advised to use caution when using common combination therapies.

Richard Glogau, MD, combines botulinum toxin with fillers to address aging around the mouth, but warns that using this approach can be tricky. “Producing symmetry in muscle action with the botulinum toxin around the mouth is difficult,” he said. To address the downturn that occurs at the corners of the mouth, dermatologists commonly use botulinum toxin in the depressor anguli oris, while using a filler in the marionette lines. The pitfall, according to Dr. Glogau, is producing exactly the same amount of muscle depression in one side as the other.

“This symmetry is important because the mouth moves very symmetrically particularly with speech. It’s a less forgiving area than botulinum toxin used on the brow area,” Dr. Glogau said.

Dermatologists avoid the asymmetry with proper dosing and placement. “When in doubt, go a little further laterally. The problem occurs usually when you put your injection points along the jawline, at the base of the depressor anguli oris muscle. You want to keep your injection point more lateral than medial. If you shoot medially the drug will infuse up into the depressor labia muscle, which controls the lower lip,” he said.